Alfawal et al.

Head & Face Medicine (2018) 14:4

https://doi.org/10.1186/s13005-018-0161-9

RESEARCH Open Access

Evaluation of piezocision and laser-assisted

flapless corticotomy in the acceleration of
canine retraction: a randomized controlled
trial
Alaa M. H. Alfawal1, Mohammad Y. Hajeer1* , Mowaffak A. Ajaj1, Omar Hamadah2 and Bassel Brad3

Abstract
Background: To evaluate the effectiveness of two minimally invasive surgical procedures in the acceleration of
canine retraction: piezocision and laser-assisted flapless corticotomy (LAFC).
Methods: Trial design: A single-centre randomized controlled trial with a compound design (two-arm parallel-
group design and a split-mouth design for each arm).
Participants: 36 Class II division I patients (12 males, 24 females; age range: 15 to 27 years) requiring first upper
premolars extraction followed by canine retraction.
Interventions: piezocision group (PG; n = 18) and laser-assisted flapless corticotomy group (LG; n = 18). A split-mouth
design was applied for each group where the flapless surgical intervention was randomly allocated to one side and
the other side served as a control side.
Outcomes: the rate of canine retraction (primary outcome), anchorage loss and canine rotation, which were assessed at
1, 2, 3 and 4 months following the onset of canine retraction. Also the duration of canine retraction was recorded.
Random sequence: Computer-generated random numbers.
Allocation concealment: sequentially numbered, opaque, sealed envelopes.
Blinding: Single blinded (outcomes’ assessor).
Results: Seventeen patients in each group were enrolled in the statistical analysis. The rate of canine retraction was
significantly greater in the experimental side than in the control side in both groups by two-fold in the first month and
1.5-fold in the second month (p < 0.001). Also the overall canine retraction duration was significantly reduced in the
experimental side as compared with control side in both groups about 25% (p ≤ 0.001). There were no significant
differences between the experimental and the control sides regarding loss of anchorage and upper canine rotation in
both groups (p > 0.05). There were no significant differences between the two flapless techniques regarding the
studied variables during all evaluation times (p > 0.05).
Conclusions: Piezocision and laser-assisted flapless corticotomy appeared to be effective treatment methods for accelerating
canine retraction without any significant untoward effect on anchorage or canine rotation during rapid retraction.
Trials registration: ClinicalTrials.gov (Identifier: NCT02606331).
Keywords: Acceleration, Piezocision, Laser-assisted, Flapless corticotomy, Minimally invasive surgical procedures,
Canine retraction

* Correspondence: [email protected]
1
Department of Orthodontics, University of Damascus Dental School,
Damascus, Syria
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 2 of 12

Background systematic review [21]. And it seems that there is no trial

Prolonged orthodontic treatment duration is considered comparing two procedures of minimally invasive corticot-
one of the most challenges that face both patients and omy. Therefore, the primary aim of this study was to
orthodontists. Increased treatment time has several side evaluate the effectiveness of piezocision versus laser-
effects such pain, discomfort, caries, white spots forma- assisted flapless cortiocotmy in accelerating canine retrac-
tion, gingival recession and apical root resorption [1, 2]. tion. The secondary aim was to evaluate dentoalveolar
So Several surgical procedures have been introduced to changes following canine retraction in terms of ‘molar
accelerate tooth movement and reduce treatment time. anchorage loss’ and ‘canine rotation’.
However, corticotomy is considered the most clinically
applied and it has been used in various forms over the Methods
past two decades [3]. Corticotomy has not been widely Study design and registration
accepted by the orthodontic community in spite of its This study was a randomized single-center controlled trial
effective in reducing orthodontic treatment time, due to with a compound design; i.e. a two-arm parallel-group
its aggressive nature so that it requires full mucoperiosteal design with a split-mouth design for each arm. There were
flaps, extensive removal of alveolar cortical bone with the no changes after trial commencement. This study was
possible post-surgical pain, swelling and hematomas [4, 5]. approved by the Local Ethics Committee of the University
Therefore, minimally invasive procedures have been of Damascus Dental School, Syria)UDDS-372-07042015/
recently developed to avoid the disadvantages of invasive SRC-2743). This study was registered with ClinicalTrials.-
corticotomy. These procedures do not require flap raising gov (https://clinicaltrials.gov;2015: NCT02606331).
and they use innovative instruments to decrease the surgi-
cal trauma. Some of these minimally invasive surgical Sample size calculation
procedures are corticision [6, 7], piezocision [8, 9], Sample size was calculated using Minitab® Version 17
computer-guided piezocision [10, 11], laser-assisted flap- (Minitab Inc., State College, Pennsylvania, USA) assum-
less corticotomy [12, 13], and micro-osteoperforations [14]. ing that a 0.75-mm (40%) increase in the amount of
The acceleratory effect of minimally invasive corticotomy canine retraction in the surgical side compared to the
has been referred initially to regional accelerated phenom- control side over 1month would be considered clinically
ena (RAP) which causes transient demineralization and significant and taking into account that the variance of
increase cellular activity that is responsible for accelerated this variable from a previous paper was 0.67 [22]. [1]
tooth movement [15, 16]. Furthermore, selective alveolar When paired t tests with a significance level of 5% and a
decortication can induce the expression of inflammatory power of 85% were imployed, 10 patients at least were
markers; raise cytokines levels and osteoclast activity which required in each group. [2] Using the same assumptions
in turns leads to rapid tooth movement [17, 18]. as before but for the sake of comparing the two tech-
Corticotomy combined with piezoelectric surgery was niques employing two-sample t tests, 16 patients at least
introduced in 2007 by Vercelotti and Podesta. Although were required in each group. To compensate for any
they recorded a significant reduction of treatment time, possible attrition (but no more thatn 10%), 18 patients
this procedure was quite invasive since it required flap were required for each group.
elevation and excessive bone removal [19] . In 2009,
Dibart et al. developed Piezocision as a minimally inva- Participants and eligibility criteria
sive technique [8], their procedure was based on small Thirty-six adult patients (24 females, 12 males) were
cuts in the buccal gingival to allow the piezosurgery enrolled in this trial, they were equally and randomly
knife to enter and perform cuts in the buccal cortical divided into two groups: piezocision group (PG; n = 18)
plate to stimulate the RAP phenomenon, and it also and laser-assisted flapless corticotomy group (LG; n =
could combine piezocison with selective tunneling when 18). A split-mouth design was employed for each group
soft or hard tissue grafting is required [20]. Recently, where the flapless surgical intervention was randomly
laser was used to perform flapless corticotomy due to its allocated to one side and the other side served as a con-
advantages. Seifi in 2012 found that flapless corticotomy trol side. Information sheets were distributed to all pa-
accomplished by ER:CR:YSGG Laser accelerated tooth tients and informed consents were obtained. All patients
movement in rats [12]. In addition, Salman and Ali fulfilled these inclusion criteria: (1) Class II division I
reported that perforations performed by Er:YAG Laser patients requiring first upper premolars extraction and
have achieved rapid canine retraction in 15 patients [13]. two-step retraction technique (2) mild to moderate skel-
Although it has been claimed that minimally invasive etal class II malocclusion (ANB ≤ 7) (3) overjet greater
corticotomy can accelerate canine retraction and reduce than 10 mm (4) normal or excessive anterior facial
treatment time, but the scientific evidence about its height which was evaluated clinically and radiography
efficacy is still limited according to a recent published through these measures (Y axis, MM, SN-MP) (5) mild
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 3 of 12

crowding ≤3 mm (6) age range between 15 and 27 years transpalatal arches were placed since the beginning of
with skeletal maturity stage ranging from CS4 to CS6 the treatment as moderate anchorage. After the comple-
using the cervical vertebral maturation method proposed ment of leveling and alignment, panoramic radiographs
by Baccetti et al., 2002 [23] (7) completion permanent were taken to evaluate paralleling of the related teeth
dentition (except of third molars) (8) no previous ortho- roots adjacent to the surgical site (canines and second
dontic treatment (9) healthy patients without systematic premolars).
diseases that could affect bone and tooth movement and
no contraindication (medical or psychological) avoid oral Surgical intervention
surgery (10) good oral hygiene and healthy periodontium All patients were asked to rinse with Chlorhexidine
which was evaluated clinically (probing depth ≤ 3 mm, Gluconate 0.12% for 1 min immediately before the surgi-
no radiograph evidence of bone loss, plaque and gingival cal intervention, then local Infiltration was injected in
index ≤1 according to Silness and Loe [24](. and the the mucobuccal fold distal to upper canines (Lidocaine
basic characteristics of the sample is given in Table 1. HCL 2% - Epinerphrine 1:80,000).Once anesthesia was
established, surgical intervention was performed in one
Randomization, allocation concealment and blinding side which had been chosen randomly. No subsequent
Simple randomization was conducted by one of the sutures were performed and the surgical side was
academic stuff (not involved in this research) at the covered by a piece of Iodoform gauze. All patients
Department of Orthodontics using computer-generated underwent the following postsurgical regimen:(1) anti-
random numbers with an allocation ratio of 1:1. Allocation biotic tables (Augmentin: 625 mg Amoxicillin 500 mg +
sequence was concealed using sequentially numbered, Clavulanate Potassium 125 mg); one tablet three times
opaque, sealed envelopes, which were opened only after the daily for 1 week, (2) rinses with Chlorhexidine Gluco-
completion of leveling and alignment stage of the dental nate 0.12% twice a day for 1 week, (3) ice packs for the
arches. Blinding of personnel and participants were not first 12 h after the surgery (4) soft diet for 2 days after
applicable. Therefore, blinding was applied only for out- the surgery (5) analgesics: acetaminophen 500 mg only if
comes’ assessor. necessary (6) nonsteroidal anti-inflammatory drugs were
forbidden to avoid overlapping with RAP phenomenon.
Leveling and alignment
The orthodontic treatment was conducted by the princi- Piezocision group (PG)
pal researcher (A.M.H.A.) under the supervision of one Piezocision was performed by the principal researcher
of the co-authors (M.Y.H.) at Orthodontic Department (A.M.H.A) under the supervision of one of the co-
of the University of Damscus Dental School. In the authors (B.B.) at Oral and Maxillofacial Surgery Depart-
beginning, first upper premolars were extracted for all ment, University of Damascus Dental School. Two inci-
patients, then leveling and alignment was performed sions in the buccal gingiva at equal distance from the
using a pre-adjusted orthodontic appliance; MBT 0.022- upper canine and 2nd premolar were done using a surgi-
in. slots size (JISCOP, Gunpo-si, Korea) with the follow- cal scalpel blade N. 15. These incisions started 3-4 mm
ing arch wires sequences: 0,014 in. NiTi or 0.016 in. apical to the interdental papilla and were 10 mm length,
NiTi (according to the amount of crowding), 0,016 × then a piezosurgery knife (BS1, Piezotome, Implant
0,022 in. NiTi, 0,017 × 0,025 in. NiTi, 0,019 × 0,025 in. Center™ 2, Satelec, France) was inserted to perform
Steel which was considered the basal arch wire. Soldered alveolar cortical incisions with 3 mm depth, which was
confirmed by the millimetric signs on the piezosurgery
knife (Fig. 1).
Table 1 Basic characteristics of the sample
PG LAFCG Total
sample
Laser-assisted flapless corticotomy group (LG)
Laser-assisted flapless corticotomy (LAFC) was con-
Sample Size 18 18 36
ducted by the principal researcher (A.M.H.A) under the
Gender (females / males) 11 / 7 13 /5 24 /12
supervision of one of the co-authors (O.H.) at the
Mean age ± SD (years) 18.70 ± 3.6 17.47 ± 3.3 18.08 ± 3.5 Higher Institution for Laser Research and Applications
Crowding (no/minimal) 3/15 5/13 8/28 (HILRA), Damascus, Syria. ER: YAG laser (LightWalker®
Facial divergence (normal/ 9/9 8/10 17/19 ST-E, Fotona, Ljubljana, Slovenia) was used from with
hyperdivergent) R14C handpiece and Cylinderical Sapphire tip (Diam-
Posterior crossbite (No /yes) 18/0 18/0 36/0 eter: 1,3 mm, Length:8 mm). Five small perforations in
Overjet increase (moderate/ severe) 6/12 7/11 13/23 the buccal gingiva at equal distance from the upper ca-
PG Piezocision group, LAFCG Laser-assisted flapless corticotomy group, SD
nine and 2nd premolar were performed using the fiber
standard deviation tip and the device was set at 100 mJ, 10 Hz, 2 W, where
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 4 of 12

Fig. 1 a: Soft-tissue incision using blade no 15. b: Vertical cortical cuts using a piezosurgery knife

each perforation was 1.3-mm wide and away from the month (T1), 2 months (T2), 3 months (T3) and 4
other perforation at a distance of 1.5-2 mm. Then the months (T4) following the onset of canine retraction.
settings were changed to 200 mJ, 12 Hz, 3 W to perform The anterior-posterior movements of upper canines and
alveolar cortical perforations with 3-mm depth (Fig. 2), first molars, and the changes in canines’ rotation were
which was confirmed with a UNC-15 probe. Both gin- assessed on dental casts at four time points (T1-T4).
gival and cortical perforations were performed under Maxillary casts were photographed digitally with focal
water-air spray cooling 40-50 mm/s and with non- projection vertical to the occlusal plane and a metal milli-
contact mode that the fiber tip was 1-2 mm away from meter ruler was placed in the same plane for the correc-
the gingiva and the alveolar bone. tion of magnification regarding the linear measurements.
The measurements were carried out on the digital photo-
Canines’ retraction graphs using AudaxCeph® version 3.4.2.2710 (Orthodontic
Canine retraction was initiated immediately after the software suite, Ljubljana, Slovenia) with the method
surgical intervention. 0,019 × 0,025 in. steel wires were described by Ziegler and Ingervall [26]. This methods
placed for all patients and nickel-titanium closed-coil depends on the localization of several references points as
springs which extended from canine brackets to first shown in Fig. 4. Then, the following variables were
molars bands, with 150-g force were used to retract measured: (1) the distance between the medial end of
canines (Fig. 3), the generated force was checked using third palatal ruga and the cusp tip of upper canine to
force gauge (040-711-00 Dentaurum, Ispringen,Ger- evaluate the anterior-posterior canine movement, (2) the
many). Patients’ follow-up appointments were every 2 distance between medial end of third palatal ruga and the
weeks to take the maximum advantage of the RAP [25]. central fossa of maxillary first permanent molar to evalu-
In each appointment, force was calibrated and readjust- ate the anterior-posterior molar movement, and (3) the
ment when necessary in order to maintain it a 150-g angle between the mid-palatal suture and the line passing
level during the whole retraction phase. through the mesial and distal margins of upper canine to
evalute canine rotation (Fig. 5).
Outcome measures The whole period of canine retraction (by months)
The primary outcome measure was the rate of canine was also recorded bilaterally in both groups, which was
movement, while the secondary outcome measures were the period between the beginning of canine retraction
molar anchorage loss, canines’ rotation and the duration until achieving Class I canine relationship. There were
of canine retraction. Alginate impressions were taken 1 no outcome changes after trial commencement.

Fig. 2 Application of perforations using the ER:YAG laser fiber tip. a: Soft-tissue perforations as a first step. b: Hard-tissue alveolar cortical perforations
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 5 of 12

Fig. 3 Canie retraction stage using NiTi closed coil springs immediatly following flapless corticotomy. a: Piezocision group. b: Laser-assisted
flapless corticotomy group

Statistical analysis interval. The Intraclass correlation coefficient test (ICC)

Because of normal distribution, paired sample t-tests were was used to determine the reproducibility of the
used to assess the differences between the control and employed method, i.e. intra-observer reliability (or ran-
experimental sides within each group, while two sample dom error), whereas paired t-tests were used to deter-
t-tests were used to compare the two experimental sides mine any systemtatic error. Bland & Altman plots were
from each group. To evaluate time-related changes, a one- also used to determine the agreement between the two
way repeated-measures ANOVA was used. All statistical measurements.
analysis were performed by one author (M.Y.H.) who was
blinded to all measurements using (Minitab® Version17, Results
StateCollege, Pennsylvania, USA). Thirty six patients were enrolled, but 2 patients (one
patient in each group) were lost to follow up due to per-
Error of the method sonal reasons. Therefore only 34 patients were enrolled
Twenty models (ten from each group) were randomly in the statistical analysis. Patients’ allocation and follow-
chosen. Digital photographs of casts have been repeated up is given in Fig. 6. Patient recruitment started in April
in the same previous manner, then all references points 2015 and ended in February 2016, and the basic charac-
were reidentified and measurments were recalculated teristics of the sample is given in Table 1.
using the same software (AudaxCeph) after a four-week For error of the method, Paired sample t-test results
showed that there was no significant difference between
the two measurements (p > 0.05). Therefore, systematic
errors were found to be small and insignificant
(Additional file 1: Table S1). The interclass correlations

Fig. 4 Landmarks used on plaster models for the analysis. 1: medial

end of right third palatal ruga, 2: medial end of left third palatal
ruga, 3: cusp tip of right canine, 4: cusp tip of left canine, 5: mesial
margin of right canine, 6: mesial margin of left canine, 7: distal
margin of right canine, 8 distal margin of left canine, 9: central fossa
of maxillary right first permanent molar, 10: central fossa of maxillary Fig. 5 Measurements on the digital photographs with the help
left first permanent molar, 11: Mid-palatal suture line of AudaxCeph
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 6 of 12

Fig. 6 CONSORT Participants’ flow diagram

coefficients (ICCs) ranged from 0.989 to 0.999 which the difference between the two experimental sides was
meant high reproducibility for the measurements made not significant (p = 0.523; Fig. 7).
on plaster models (Additional file 2: Table S2). Also Bland The rate of canine retraction decreased significantly
& Altman plots demonstrated a very good agreement be- over time in the two experimental sides of both groups
tween the two measurements (Additional file 3: Table S3). (p = 0.006 in the PG, p = 0.003 in the LG; Table 5).
The rates of upper canines’ retraction were signifi- No harms were observed with piezocision and laser-
cantly higher in the experimental sides than in the assisted flapless corticotomy group during the present study.
control sides during the first 2 months in both groups
(p < 0.001; Table 2). Regarding the loss of anchorage, Discussion
there were no significant differences between the experi- According to our knowledge, this is the first trial in the lit-
mental and control sides in both groups during the four erature comparing two techniques of minimally invasive
evaluation times (p > 0.05; Table 3). The rates of canines’ corticotomy in terms of canine retraction speed, since the
rotation were greater in the experimental sides than in available evidence about the efficacy of minimally-invasive
the control sides in both groups during all evaluation surgically-assissted orthodontics (MISAO) has been
times, however these differences were negligible and shown to be limited in a recent review [21].
insignificant (p > 0.05; Table 4). There were no signifi- Extraction of premolars was conducted in the begin-
cant differences between the two experimental sides in ning of treatment and before appliance fitting in order
both groups during all evaluation times for the three to allow for quicker leveling and alignment without
previous variables (p > 0.05; Tables 2, 3 and 4). causing additional proclination for the anterior teeth. In
The overall duration of canine retraction was short- addition, extraction of premolars before leveling and
ened significantly in the experimental side compared to alignment is the usual scenario for Class II division 1
the control side by a mean of 1.17 month (p = 0.001) in patients treated at our department and this may help in
the PG and 1.05 month (p ≤ 0.001) in the LG whereas evaluting the pure impact of corticotomy when
 Alfawal et al. Head & Face Medicine (2018) 14:4

Table 2 Descriptive statistics of the canine retraction rate (mm/month) as well as the p-values of significance tests
Time PG (n = 17) LAFCG (n = 17) PG Vs LAFCG
Experimental side Control side Mean Diff (95% CI) P-Value† Experimental side Control side Mean Diff (95% CI) P-Value† Mean Diff (95% CI) P-Value ††
Mean SD Mean SD Mean SD Mean SD
T0-T1 (1st month) 1.65 0.40 0.83 0.18 0.82 (0.67, 0.96) < 0.001*** 1.57 0.36 0.79 0.11 0.78 (0.62, 0.93) < 0.001*** 0.08 (− 0.19, 0.35) 0.554
T1-T2 (2nd month) 1.38 0.32 0.88 0.14 0.50 (0.36, 0.63) < 0.001*** 1.25 0.30 0.85 0.14 0.40 (0.28,0.52) < 0.001*** 0.12 (− 0.09, 0.35) 0.248
T2-T3 (3rd month) 1.10 0.29 0.98 0.22 0.11 (− 0.04, 0.26) 0.134 1.06 0.28 0.96 0.25 0.10 (− 0.06,0.27) 0.220 0.03 (− 0.18, 0.25) 0.738
T3-T4 (4th month) 0.87 0.11 0.94 0.09 −0.07 (− 0.20, 0.06) 0.231 0.89 0.16 0.90 0.16 −0.01 (− 0.16, 0.13) 0.791 − 0.01 (− 0.20, 0.17) 0.886
T0-T4 1.19 0.16 0.90 0.09 0.29 (0.12, 0.46) 0.007** 1.14 0.10 0.84 0.05 0.30 (0.14, 046) 0.006** 0.05 (− 0.14, 0.24) 0.564
†: Paired t test, ††: two-sample t test, *Significant at P < 0.05, **Significant at P < 0.01, ***Significant at P < 0.001, PG Piezocision group, LAFCG Laser-assisted flapless corticotomy group, SD standard deviation, Mean Diff
mean difference, CI Confidence interval
Page 7 of 12
 Alfawal et al. Head & Face Medicine (2018) 14:4

Table 3 Descriptive statistics of molar movement rate (mm/month) as well as the p-values of significance tests
Time PG (n = 17) LAFCG (n = 17) PG Vs LAFCG
Experimental side Control side Mean Diff (95% CI) P-Value† Experimental side Control side Mean Diff (95% CI) P-Value† Mean Diff (95% CI) P-Value ††
Mean SD Mean SD Mean SD Mean SD
T0-T1 (1st month) 0.65 0.26 0.77 0.24 −0.11 (−0.26, 0.02) 0.103 0.61 0.20 0.69 0.20 −0.08 (− 0.20, 0.03) 0.159 0.04 (− 0.12, 0.21) 0.589
T1-T2 (2nd month) 0.53 0.24 0.66 0.25 −0.13 (− 0.28, 0.01) 0.074 0.50 0.21 0.65 0.27 −0.14 (− 0.29, 0.01) 0.067 0.02 (− 0.13, 0.19) 0.750
T2-T3 (3rd month) 0.47 0.22 0.51 0.23 −0.04 (− 0.12, 0.02) 0.196 0.49 0.20 0.54 0.21 −0.05 (− 0.14, 0.03) 0.236 − 0.02 (− 0.18, 0.14) 0.796
T3-T4 (4th month) 0.28 0.09 0.32 0.11 −0.03 (− 0.13, 0.05) 0.322 0.32 0.22 0.33 0.19 −0.00 (− 0.15, 0.14) 0.876 − 0.03 (− 0.26, 0.19) 0.721
†: Paired t test, ††: two-sample t test, *Significant at P < 0.05, **Significant at P < 0.01, ***Significant at P < 0.001, PG Piezocision group, LAFCG Laser-assisted flapless corticotomy group, SD standard deviation, Mean Diff
mean difference, CI Confidence interval
Page 8 of 12
 Alfawal et al. Head & Face Medicine (2018) 14:4

Table 4 Descriptive statistics of the canine rotation rate (degrees/month) as well as the p-values of significance tests
Time PG (n = 17) LAFCG (n = 17) PG Vs LAFCG
Experimental side Control side Mean Diff P-Value† Experimental side Control side Mean Diff P-Value† Mean Diff P-Value††
(95% CI) (95% CI) (95% CI)
Mean SD Mean SD Mean SD Mean SD
T0-T1 (1st month) 8.00 2.82 6.93 2.29 1.06 (−0.09, 2.22) 0.070 6.88 3.07 6.11 2.20 0.76 (−0.36, 1.89) 0.170 1.11 (−0.98, 3.22) 0.287
T1-T2 (2nd month) 6.54 2.88 6.19 2.43 0.34 (−0.51, 1.20) 0.403 5.82 2.26 5.59 2.53 0.23 (−0.57, 1.04) 0.544 0.71 (−1.11, 2.54) 0.433
T2-T3 (3rd month) 5.42 2.14 5.14 2.30 0.28 (−0.52, 1.09) 0.461 5.00 2.04 4.75 2.23 0.24 (−0.54, 1.04) 0.517 0.42 (−1.13,1.99) 0.580
T3-T4 (4th month) 3.22 1.44 2.82 0.61 0.40 (−0.61, 1.41) 0.355 3.39 1.62 2.53 0.99 0.86 (−1.23, 2.95) 0.316 −0.16 (−2.25, 1.91) 0.859
†: Paired t test, ††: two-sample t test, *Significant at P < 0.05, **Significant at P < 0.01, ***Significant at P < 0.001, PG Piezocision group, LAFCG Laser-assisted flapless corticotomy group, SD standard deviation, Mean Diff
mean difference, CI Confidence interval
Page 9 of 12
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 10 of 12

Fig. 7 Comparison the duration of canine retraction (months) between two experimental sides in both groups

performed after leveling and alighment stage instead of removal of alveolar bone could also stimulate the ex-
being performed in conjunction with extractions. pression of inflammatory markers and increase the levels
NiTi closed coil springs were used to retract canines of cytokines that lead to raise the activity of osteoclasts
because they generate a continuous light force and pro- which in turn enhance bone remodeling and accelerate
vide better oral heath compared to elastomeric chains tooth movement [17, 18]. Occurrence the acceleration in
[27]. Canine retraction was initiated immediately after the first 2 months only and the gradual decrease in ca-
the surgical intervention and patients were followed nine retraction speed could be attributed to the transient
every 2 weeks instead of 4 weeks to take the maximum nature of the RAP. Wilcko et al. reported that this
advantage of the RAP due to its transient nature [25]. phenomenon had a specific pattern in its emergence and
Medial ends of the third palatal rugae were used as extent since it was found to start within few days follow-
stable landmarks to measure the antero-posterior move- ing injury reaching its peak after 4 to 8 weeks and last-
ments of the canine and first molar. Several studies have ing for 2 to 4 months [29, 30]. However, in the current
demonstrated that measurements taken relative to the study the RAP peaked after a month and decreased dra-
third palatal rugae can be used as reliable as cephalo- matically at the end of the second month. The difference
metric superimposition [28]. between the current findings and those of Wilcko et al.
The rates of upper canines’ retraction were signifi- could be explained by the more aggressive nature of
cantly higher in the experimental sides than in the their intervention compared to that of the current trial.
control sides in both groups. This acceleration might be The rate of canine retraction in the first month was sig-
explained by the induced RAP and to reduced alveolar nificantly higher in the piezocision side than in the con-
bone resistance to tooth movement [15, 16]. Selective trol side by approximately two-fold. The rate was still

Table 5 Descriptive statistics of the changes in the rate of canine movement over time in the experimental side for each group as
well as the results of significance tests using repeated measures ANOVA and its post-hoc tests
Time Comparisons Piezocision group Laser-assisted flapless corticotomy group
Mean P-Value* 95% CI Mean P-Value* 95% CI
Diff. Diff.
Lower bound Upper bound Lower bound Upper bound
T1 T1-T2 0.21 0.013 0.06 0.35 0.46 0.062 −0.03 0.96
T1-T3 0.41 0.045 0.01 0.81 0.74 0.023 0.16 1.31
T1-T4 0.63 0.001 0.37 0.89 0.74 0.012 0.27 1.22
T2 T2-T3 0.20 0.141 −0.16 0.56 0.27 0.275 − 0.33 0.88
T2-T4 0.42 0.057 0.28 0.57 0.28 0.065 −0.02 0.59
T3 T3-T4 0.22 0.107 −0.05 0.49 0.00 0.969 −0.39 0.40
*Significant at P < 0.05, Least Significant Difference (LSD) post-hoc tests were employed, Mean Diff mean difference, CI confidence interval
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 11 of 12

1.5 times greater in the second month. These findings In a recent study about patients’ and orthodontists’
agree with those of Aksakalli et al. [22] and Abbas et al. perectpions towards reducing treatment time [32] it was
[31] who reported that piezocision was able to accelerate found that orthodontists would be interested to use a
the rate of canine retraction significantly by 1.5-2 times modern acceleration technique if it can reduce orthodon-
during the first 3 months of tooth movement. tic treatment time by 20-40%. Therefore, it seems that
The rate of canine retraction was significantly faster in both piezocision and laser-assisted flapless corticotomy
the laser-assisted flapless corticotomy compared to the con- are possible adjunctive modalities in the acceleration of
trol side by an approximately 2 times during the first orthodontic tooth movement since they were found to
month of follow-up. One recent trial conducted by Salman shorten canine retraction time by approximately 25%.
and Ali [13] evaluated laser-assisted flapless corticotomy
and showed that there was an increase in canine retraction Limitations
speed by two-fold during a six-week follow-up period. Although no adverse effects were observed with the two
However, there were some shortcomings with their study minimally invasive corticotomy procedures in the present
design such as the short follow-up time as well as the poor study, cost-benefit ratio and patient-reported outcomes
reporting of their outcome measures. have not been evaluated systematically. This study did not
Also the results of the current study in both groups measure the nature of canine retraction tipping or transla-
agreed with Alikhani et al. [14] who showed that micro- tion. Furthermore the current trial did not evaluate sex-
osteoperforations accomplished by ‘PROPEL’ device related possible differnces in tooth movement rate and
significantly increased the speed of canine retraction this should be taken into account in future similar work.
during the first month of observation. Therefore, the generalizability of the findings of the
In the current study there were no significant differ- current trial might be representative to some extent.
ences between the experimental and control sides in both
groups regarding the loss of anchorage which is compat-
ible with the findings of Abbas et al. [31]. The speed of Conclusion
anchorage loss ranged from 0.28 to 0.65 mm/month in On the basis of the current study the following points
the piezocision group and from 0.32 to 0.61 mm/month can be concluded:
in the Laser-assisted flapless corticotomy group; therefore,
these amounts were deemed non-significant from the 1. Piezocision and laser-assisted flapless corticotomy
clinical point of view. seemed to be effective techniques for accelerating
The rate of canines’ rotation in the surgical side in canine retraction; canine retraction was two times
both groups was greater compared to the control side. faster than the conventional retraction in the first
This can be due to the greater amount of retraction in month and 1.5 times faster in the second month.
the surgical side and to low alveolar bone density caused 2. Piezocision and laser-assisted flapless corticotomy
by surgical trauma. However the increase of canine had no significant effects on anchorage loss or
rotation was not significant in the current study, it could canine rotation during rapid retraction.
be explained by the conservative nature of the applied
surgical interventions in the current study without pro- Additional files
ducing a significant weakening of alveolar cortical bone
that would allow the upper canines to rotate consider- Additional file 1: Table S1. Assessment of the systematic error in the
current study. (DOCX 19 kb)
ably during retraction.
Additional file 2: Table S2. Intraclass correlation coefficients of
There were no significant differences between piezoci- repeated measurements in the current study for the assessment of
sion and laser-assisted flapless corticotomy regarding all random error. (DOCX 27 kb)
studied variables. This might be attributed to the minim- Additional file 3: Table S3. Levels of agreement of the performed
ally invasive nature of these two techniques, since they measurements in this current study according to Bland and Altman’s
analysis. (DOCX 25 kb)
do not require flap elevation or suturing. Both tech-
niques used innovative tools which were associated with
fast healing of the alveolar bone (piezotome and ER:YAG Abbreviations
HILRA: Higher institution for laser research and applications; LAFC: Laser-assisted
laser). In addition, the amount of surgical injury was flapless corticotomy; LG: Laser-assisted flapless corticotomy group; MISAO: Minimally-
probably similar between the two techniques in spite of invasive surgically accelerated orthodontics; PG: Piezocision group; PROPEL: A
the difference in the design of incisions and bone manual device could make tiny, pre-measured holes through the gingiva and alveo-
lar bone; RAP: Regional accelerated phenomena
cutting. No trial has been found in the literature com-
paring these two techniques, and therefore, it was diffi-
Funding
cult to compare the curring findings with any available This work was supported by the University of Damascus Postgraduate
published study. Research Budget (Ref no: 83054206781DEN).
Alfawal et al. Head & Face Medicine (2018) 14:4 Page 12 of 12

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Ethics approval and consent to participate
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The Local Ethics Committee of the University of Damascus Dental School,
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Consent for publication
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Not applicable.
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Springer Nature remains neutral with regard to jurisdictional claims in
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Author details
1 25. Sebaoun JD, Surmenian J, Dibart S. Accelerated orthodontic treatment with
Department of Orthodontics, University of Damascus Dental School,
piezocision: a mini-invasive alternative to conventional corticotomies.
Damascus, Syria. 2Department of Oral Medicine, University of Damascus
Orthod Fr. 2011;82:311–9.
Dental School, Damascus, Syria. 3Department of Oral and Maxillofacial
26. Ziegler P, Ingervall B. A clinical study of maxillary canine retraction with a
Surgery, University of Damascus Dental School, Damascus, Syria.
retraction spring and with sliding mechanics. Am J Orthod Dentofac
Orthop. 1989;95:99–106.
Received: 11 August 2017 Accepted: 2 February 2018
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